Last week, I happened to see this Facebook post of the The Medical Registrar where she offends a GP, Anne Marie Cunningham*, who wrote a critical post about black medical humor at her blog “Wishful Thinking in Medical Education”. I couldn’t resist placing a likewise “funny” comment in this hostile environment where everyone seemed to agree (till then) and try to beat each other in levels of wittiness (“most naive child like GP ever” – “literally the most boring blog I have ever read”, “someone hasn’t met many midwives in that ivory tower there.”, ~ insulting for a trout etc.):

“Makes no comment, other than anyone who uses terms like “humourless old trout” for a GP who raises a relevant point at her blog is an arrogant jerk and an unempathetic bastard, until proven otherwise… No, seriously, from a patient’s viewpoint terms like “labia ward” are indeed derogatory and should be avoided on open social media platforms.”

I was angered, because it is so easy to attack someone personally instead of discussing the issues raised.

Perhaps you first want to read the post of Anne Marie yourself (and please pay attention to the comments too).

Anne Marie mainly discusses her feelings after she came across a discussion between several male doctors on Twitter using slang like ‘labia ward’ and ‘birthing sheds’ for birth wards, “cabbage patch” to refer to the intensive care and madwives for midwives (midwitches is another one). She discussed it with the doctors in question, but only one of them admitted he had perhaps misjudged sending the tweet. After consulting other professionals privately, she writes a post on her blog without revealing the identity of the doctors involved. She also puts it in a wider context by referring to the medical literature on professionalism and black humour quoting Berk (and others):

“Simply put, derogatory and cynical humour as displayed by medical personnel are forms of verbal abuse, disrespect and the dehumanisation of their patients and themselves. Those individuals who are the most vulnerable and powerless in the clinical environment – students, patients and patients’ families – have become the targets of the abuse. Such humour is indefensible, whether the target is within hearing range or not; it cannot be justified as a socially acceptable release valve or as a coping mechanism for stress and exhaustion.”

The doctors involved do not make any effort to explain what motivated them. But two female anesthetic registrars frankly comment to the post of Anne Marie (one of them having created the term “labia ward”, thereby disproving that this term is misogynic per se). Both explain that using such slang terms isn’t about insulting anyone and that they are still professionals caring for patients:

It is about coping, and still caring, without either going insane or crying at work (try to avoid that – wait until I’m at home). Because we can’t fall apart. We have to be able to come out of resus, where we’ve just been unable to save a baby from cotdeath, and cope with being shouted and sworn at be someone cross at being kept waiting to be seen about a cut finger. To our patients we must be cool, calm professionals. But to our friends, and colleagues, we will joke about things that others would recoil from in horror. Because it beats rocking backwards and forwards in the country.

[Just a detail, but “Labia ward” is a simple play on words to portray that not all women in the “Labor Ward” are involved in labor. However, this too is misnomer. Labia have little to do with severe pre-eclampsia, intra-uterine death or a late termination of pregnancy]

To a certain extent medical slang is understandable, but it should stay behind the doors of the ward or at least not be said in a context that could offend colleagues and patients or their carers. And that is the entire issue. The discussion here was on Twitter, which is an open platform. Tweets are not private and can be read by other doctors, midwives, the NHS and patients. Or as e-Patient Dave expresses so eloquently:

I say, one is responsible for one’s public statements. Cussing to one’s buddies on a tram is not the same as cussing in a corner booth at the pub. If you want to use venting vocabulary in a circle, use email with CC’s, or a Google+ Circle.One may claim – ONCE – ignorance, as in, “Oh, others could see that??” It must, I say, then be accompanied by an earnest “Oh crap!!” Beyond that, it’s as rude as cussing in a streetcorner crowd.

Furthermore, it seemed the tweet served no other goal as to be satirical, sardonic, sarcastic and subversive (words in the bio of the anesthetist concerned). And sarcasm isn’t limited to this one or two tweets. Just the other day he was insulting to a medical student saying among other things:“I haven’t got anything against you. I don’t even know you. I can’t decide whether it’s paranoia, or narcissism, you have”.

We are not talking about restriction of “free speech” here. Doctors just have to think twice before they say something, anything on Twitter and Facebook, especially when they are presenting themselves as MD. Not only because it can be offensive to colleagues and patients, but also because they have a role model function for younger doctors and medical students.

Isolated tweets of one or two doctors using slang is not the biggest problem, in my opinion. What I found far more worrying, was the arrogant and insulting comment at Facebook and the massive support it got from other doctors and medical students. Apparently there are many “I-like-to-exhibit-my-dark-humor-skills-and-don’t-give-a-shit-what-you think-doctors” at Facebook (and Twitter) and they have a large like-minded medical audience: the “medical registrar page alone has 19,000 (!) “fans”.

Sadly there is a total lack of reflection and reason in many of the comments. What to think of:

“wow, really. The quasi-academic language and touchy-feely social social science bullshit aside, this woman makes very few points, valid or otherwise. Much like these pages, if you’re offended, fuck off and don’t follow them on Twitter, and cabbage patch to refer to ITU is probably one of the kinder phrases I’ve heard…”

and

“Oh my god. Didnt realise there were so many easily offended, left winging, fun sponging, life sucking, anti- fun, humourless people out there. Get a grip people. Are you telling me you never laughed at the revue’s at your medical schools?”

and

“It may be my view and my view alone but the people who complain about such exchanges, on the whole, tend to be the most insincere, narcissistic and odious little fuckers around with almost NO genuine empathy for the patient and the sole desire to make themselves look like the good guy rather than to serve anyone else.”

It seems these doctors and their fans don’t seem to possess the communicative and emphatic skills one would hope them to have.

One might object that it is *just* Facebook or that “#twitter is supposed to be fun, people!” (dr Fiona)

I wouldn’t agree for 3 reasons:

Doctors are not teenagers anymore and need to act as grown-ups (or better: as professionals)

There is no reason to believe that people who make it their habit to offend others online behave very differently IRL

Seeing Twitter as “just for fun” is an underestimation of the real power of Twitter

You can already start submitting to the next edition (just sign in and enter the URL of your post) at the submission form here.

The next edition will be hosted by Guus van den Brekel at DigiCMB. I don’t remember know if Guus has a theme in mind, we will hear next week when Guus is back from vacation. But you can submit any post as long as it is of good quality and pertains to medical information.

By the way this might be the last MedLibs Round.…

No, I don’t mean we will stop with the blog carnival. It will possibly be renamed, depending on the outcome of the poll below.

If you would like to host this blog carnival, please let me know (at this blog, at twitter (laikas) or by mail (laika dot spoetnik at gmail dot com). Starting bloggers are welcome too. All months in 2011 are still available, so you can choose.

Of all social networking sites, Facebook causes the greatest privacy concerns. Certainly since it has changed its privacy options over time.

In the beginning, Facebook restricted the visibility of a user’s personal information to just their friends and their “network”, but the default privacy settings have become much more permissive, as you can see in the video below.
This short video is based on a visualization made by Matt McKeon and gives only an impression of a work-in-progress
(for up to date info check the original animation at http://mattmckeon.com/facebook-privacy/).

The reason? According Facebook founder Mark Zuckerberg the controversial new default and permanent settings just reflect the way the world has changed, becoming more public and less private (see ReadWriteWeb).

“Default” is the key to the problems. You have to opt out to protect your privacy. However to fully protect your privacy on Facebook, you have to navigate through 50 settings with more than 170 options (see great charts at the NY Times!). Facebook’s privacy policy is longer than the American constitution!!!

Shocked by the results of the ACLU’s Facebook Quiz (see Mashable), I already changed my privacy settings last summer. Doing a simple quiz on Facebook meant everything on your profile (whether you use privacy settings or not), is available to the quiz. Even more worrying, when your friends do a quiz, everything on your profile is made available to the developers as well.

Since the default privacy settings have changed, my settings needed to be adapted again. But where were the leaks in the 170 options?

Luckily there is a very simple bookmarklet Reclaim Privacy that can check and fix your profile in 2 minutes (see Mashable.com) It is very easy.

1. First go to Reclaim Privacy and drag the bookmarklet to your web browser bookmarks bar
(in the example I dragged the bookmarklet into Chrome’s bookmarks (upper arrow)

3. You will see a series of privacy scans that inspect your privacy settings and warn you about settings that might be unexpectedly public.
In my case my friends could still accidentally share my personal information. This is indicated by a red sign: “insecure“.

4. So I clicked “prevent friends from sharing your data”, and in seconds this was the result:

5. I tweaked the contact information a bit (caution) by changing my contact settings, but I still would allow everyone to add me as a friend (I still have to approve, don’t I?)

By way of exception I write a Dutch blog post to respond to an article in a Dutch Newspaper ridiculing speakers, writers, chatting and twittering people in a long-winded (3 pages) pompous, “literary” way, saying that they are terrorizing dictators. Although the writer, Thomése, might be right in some respects (all people want to express their opinion, want to be heard, but nobody listens), his critique just hits the topic superficially. By doing so, the article adds to the already existing misunderstandings regarding social media. I finish my review by expressing the wish that Thomése mastered the art of Tweeting: be social, clear and comprehensive in 140 characters.

Before I went on vacation (July 14th) I started a blogpost about Clinical Reader, a new aggregator. However, a Twitter riot -started July 13th- drastically changed my view of Clinical reader and I decided to await further developments till my return. Alas, things have only worsened.

The adapted blogpost consists of two parts: a neutral look from the outside (original draft) and a look behind the scenes: how social media and web 2.0 tools should not be used.

I submit this post to the Grand Rounds, not only to inform you about a potential fancy aggregator, but also to warn potential users to “look before you leap”.

Please note that the figures shown in the first part are all screendumps taken at July 13th or earlier and might no longer exist in this form (note added after publication, as all sentences in this color)

Most of these readers (can) track medical journals or news, some (can) also track blog posts and web 2.0 tools (like PeRSSonalized Medicine and MedWorm). PeRSSonalized Medicine excels by the input from the readers (doctors, health 2.0 people and patients), Amadeo and especially Medworm have large lists of journals to choose from. All these aggregators can be personalized. Of course Netvibes,I-Google andRSS-Readers give the utmost freedom in compiling list feeds, but one first has to learn how to use them. And although it is not difficult, it means a hurdle to many.

We are building a user-friendly platform that will enable medical professionals around the world the ability to easily interact with the latest developments in their respective specialties. Our aim is to bring academic content together and create a semantic digital medical library.

——————

2. What it is and what it isn’t.

Clinical Reader is website that syndicates content via RSS/Atom (aggregator), enabling busy clinicians to easily browse top medical journals, health news sources and multimedia without having a clue what RSS is about (and for free). The same is true for other aggregators discussed previously: PeRSSonalized Medicine, Amedeo and MedWorm. In fact the presentation of the feeds looks pretty similar (see Fig. for comparison of Clinical Reader and Perssonalized Medicine). Disadvantage of these kind of aggregators is that only the first items are shown, and as these often are editorials, comments, correspondence and news, the physician still has to follow the link to the journal to see most of the (true) articles.

In contrast to the aforementioned services, the “RSS-feeds” of Clinical Reader cannot be personalized (a personal selection of journals). There is however the possibility to select an entire clinical section, each with its own selection of specialist journals. And according to Rashada Henry, associate editor of ClinicalReader.com (commenting on Bertalan Mesko’s post), open or closed personal pages may become an option in due course.

3. What’s new?

As said, the idea isn’t new, Clinical Reader is an old concept in a new guise. But what a guise. It is a glimmering site with prints of the main journals on the home page. It has the appearance of an i-pod touch: you can scroll the sources with your mouse and click the ones you would like to read. Wow, I was immediately taken by it.

4. Coverage

The emphasis is on medical journals and news. But there is also a page for with a selection of 14 Medical Blogs. There are also plans to include top Twitter doctors worth following (spreadsheet prepared by Ves Dimov, MD), for nurses, open access … and top medical librarians blogs (worth following for doctors). Following Ves’ example I made a spreadsheet of useful medical librarian blogs, open to editing here

The original spreadsheet looked like this:

The preview of the medical librarian page (how it would look when incorporated) looked like this.

Apart from the fact that the site was not as revolutionary as suggested, there were some basic things about the site that were of some concern. The “About us” section contains no names, picture, verifiable info, etc. It only says: “Clinical Reader was brought to life in 2009 by a junior doctor and a small group of forward thinking young tech programmers spread across London and Toronto.” Furthermore I wondered whether NLM would ever give stars to commercial tools like this. I wondered, but no more than that….

1. Starry ethics fail
Nikki Dettmar, a medical librarian at the National Network of Libraries of Medicine (NNLM) did take a closer look. In a blogpost Starry ethics fail she says that:

it is with concern that I’ve heard about some of my colleagues promoting and collaborating with the newly launched company, Clinical Reader.

Why? (red scrawl emphasis mine)

This above-the-page-fold graphic is intentional (not accidental, this is clear marketing intent to lend quick visual credibility to the organization) and currently displayed everywhere (homepage, sections pages, multimedia page, the newsletter, etc.) throughout the resource.

It is bogus as far as the National Library of Medicine (NLM) is concerned since the U.S. Government doesn’t endorse or grant 5 stars to anything. The NLM Copyright Information page offers more elaboration, ….

Clinical Reader also currently uses two copyrighted images on their Partners (specific original source, copyright notice at bottom) and Advertising pages (from somewhere on Signalnoise). A ‘credit’ link to a source doesn’t honor an image copyright. (….) Commercial organizations can well afford to purchase or design their own graphics.

In a later post, Nikki also showed that the multimedia wrongfully used SpringerImages, that must not be (…) used for commercial purpose including the placement or upload of the Licensed Content on a commercial entity’s internet website.

In addition, the logo that was used by Clinical Reader to indicate the untangling of a maze of information (that I copied in my original draft above), was taken without permission from the website of FeedStitch where it was created by their designer Owen Shifflett. (see discussion).

You kind of wonder what wasn’t copied.

3. Threat to Nikki (Eagledawg) via Twitter

For me the most astonishing event was the immature “response” of Clinical Reader to Nikki after publishing her first post with appropriate critique. It was in the from of a real threat.

I immediately responded (while packing) to the initial threat and so did dozens of other medical librarians. Mostly on Twitter and Friendfeed, but also via their blogs (see below and Nikki’s blog). Some also retracted their initial support (i.e. see this mail of Connie Schardt, who like many of us -including me- was “temporarily dazzled by the flashy display and ease of use of the product.”)

4. Change of Twitter-accounts, deleting tweets

Quite confusingly Twitter-accounts have been changed and deleted. First initials appeared after tweets to designate the person who tweeted for @clinicalreader, which I thought was a good thing. I followed @clinicalreader, but now the account was discontinued. The archive was kept at @clinical_tweets, which vanished as well. Now there is @clinical_reader, that states that tweeting has not really begun?? The only Clinical Reader account I know of is that of allan_marks. ALL previous tweets have been deleted. What remains are dm’s (direct messages) and tweets that are preserved by services like QuoteURL.(for a detailed account of the switching of the original Twitter account’s name ‘at the speed of light’ see this blogpost of pegasuslibrarian)

It is all very confusing. Why would one do that other to conceal what has been said?

One salient detail. At their website Clinicalreader still refers to @clinicalreader, which is taken over by someone taking the opportunity to register the account when it moved to @clinical_tweets

5. More lying

There are several examples of making up retweets (quoting someone), see here (@ClinicalReader “I didn’t RT anything from y’all. Y’all aren’t very good at the whole social media thing, huh?”-David Rothman) and here (@ClinicalReader – “Would you mind not attributing fabricated quotes to me please? I never said this: http://tr.im/sCFb#ClinicalCheater“) (source: 6)

6. Denial

The behaviors of the ones in charge are so immature. It’s really unbelievable. You always have to take critique seriously, and if you choose to use social media and make a mistake, than apologize openly (see the blogpost of Peter Murray below, 7).

Look at this discussion with Ben Goldacre (thanks Nikki). It is really ridiculous, QuoteURL: one, two, three, and four. Clinical Reader is playing dumb.

I might not have been exhaustive, but I know enough for the moment. Also in my eyes, Clinical Reader has lost all its credibility.

Twitter is only for people telling what they’re doing right now, like “what they eat for breakfast”. Right?
Twitter is a kind of web based Short Message Service, which is largely for ego-trippers sharing the -largely uninteresting- private parts of their life, isn’t it?YouTube is mostly for teens and twenties enjoying music videos. And similarly Facebook and (in Holland Hyves) are just a hype. O.k.?
And blogging, ha, blogging…. Doctors shouldn’t blog, because of privacy issues and because it is a waste of time. Doctors don’t even have time for it, nor should they have… Yes?!

Social media are useless and perhaps even “dangerous” (distracting staff, viruses, wrong info, privacy concerns) and hospitals should keep them behind their firewalls!!

Right?

Wrong!

Wrong. At least that is what many US hospitals are thinking. More and more they are embracing social media. Why? To connect, to interact, to disseminate new research, to share in-depth medical information and to gather communities of employees, patients and their families.

One tool they use is Twitter (@mayoclinic). First they protected their updates on Twitter, didn’t follow their followers back. Twitter was mainly used for“branding”, but later they realized that this didn’t work and that “they needed more than an audience”. By interacting with their followers they got more response. They also reached more people, because interesting tweets were retweeted by their followers. So even people that don’t follow @mayoclinic (but are followers of its followers) are alerted to the news. It is also an important virtual mouth-to-mouth-tool for new patients.

More than Facebook, Twitter enables you “to connect with people you don’t know but share the same interest with. It is for the friends you don’t know yet”

Mayo Clinic actively supports its staff and its patients to use the social media tools.

The first preliminary list of Dutch hospitals officially using social media has now been compiled by Lucien et al. It should be stressed that the list is based on what is known, but needs to be confirmed the hospitals (a mailing is being send). See blogpost on Zorg 2.0 (Dutch) and this pdf with preliminary data.

There is reason to believe that the results will not be essentially different.

Indeed, I don’t know of any initiatives of our hospital to use social media (Academic Medical Center, Amsterdam)

Thus looking at the enormous differences between the USA and the Netherlands one wonders:

Europe (the Netherlands) isn’t it about time that you join?
At least get acquainted with Social Media and Web 2.o!
Look what others are doing and see what is in it for you, your staff ànd your patients!
You may not (want to) do it, but your patient will do it anyway.

By the way, 5 days ago I personally experienced that Mayo Clinic is really interactive. I followed one of their links in their tweets to find that I could not access the news item they referred to, because it was password protected. I tweeted about it -just in general-. Mayoclinic immediately picked this message up (because they have a search for “mayoclinic” on Twitter). But more importantly they immediately responded in a pleasant way ànd immediately took care of it. This illustrates that they are not only “interactive” in words but also in deeds: they really “listen” and “respond” to their Twitter followers. Many individuals on Twitter don’t even bother.

Some of these tools are just for fun, others (the last 3 for instance) tell you something about somebody’s twitter network or tweets.
In the last category a new tool has just been launched: Top Twitter Friends on http://twitter.mailana.com/. It is meant to answer the questions: Who do you talk to most often on Twitter? Who are your closest friends (BFF’s)? and What does your social network look like? But it gives also tips on who you should follow, how to find friends in your neighborhood (not successful in my hands) and to find a network of people talking about a certain topic.

I like this tool very much, because it visualizes the network of your relevant contacts and their contacts. My present network looks like this:

I’m automatically in the center. The thicker the threads with people, the more conversations you had with them. DM’s (direct messages) are excluded. When you pass your mouse over a portrait all rays starting from there color red. Within your network, other networks may be visible. For instance, in my network you see a “Dutch community” (wowter, gbierens, essen2punt0 etc) and an Australian one (@dreamingspires, @sandnsurf, bitethedust). Some people are pivots themselves: like @mikehawker and @scanman.
You can see anyone’s network by clicking a portrait or typing a name.

A list of your 10 closest “friends” is also shown. My closest “friend” is symtym, runners up are the librarians @pudliszek and @shamsha. And there is a list of 10 suggestions as well.

Finally you can make a map of conversations. The following map was created by searching for the hashtag #zorg20 (a dutch health 2.0 meeting). It will be no surprise that the organizer @zorg2.0 is almost in the center.

This tool looks really awesome.
However, it makes you realize that all your tweets and follows are charted. Can this be used to pick up people’s conversation at certain topics? Can it be misused?I just wondered when I noticed that this system is driven by Mailana social network analysis system (see demo here). This system enables companies to find out valuable hidden information in company e-mails. As shown in the demo, you can search for a company name in Mailana and find which employees mail most about it. You even get a wordcloud on basis of which you can decide who gives you the most valuable information. It is easy to see how that can be used and misused in a company. Would you like your email to become searchable? I wouldn’t! Twitter is an open communication network, but still…..

….while the ‘laypeople’ are chattering away (…) a company called Salesforce.com has launched a product to allow “companies to search, monitor and join conversations taking place on Twitter directly in the Service Cloud.”(for more details see post here).